QUESTION:

Thoughts about completing a wean for infants as young as 8 months? (this patient I’m considering a thickener wean with is 12 months gestational age, 8 months correct, ex 22-weeker)

How do you manage nipple flow rates as you progress through the weaning process? i.e., patient is on a level 4 nipple, consuming formula thickened with 1 tsp per fluid oz.

What if the patient takes varying amounts of formula per feed? i.e., patient will sometimes consume 4 oz then the next feed, will consume 5 oz. I work primarily with low-income families in which parents use WIC, so I’m trying to prevent them from wasting formula. The study I’m referring to (Wolter et al 2018) uses 6 oz in their recipe.

I’m fairly new to utilizing this process in my practice.

CATHERINE’S ANSWER:

This infant sounds quite complex. I am wondering about the swallowing pathophysiology objectified in radiology that led to the need for thickening and how precarious that physiology was, even with thickening. The majority of our former 22 weekers have enduring multiple complex comorbidities and are often silent aspirators. Within this high risk patient group we often find the weaning protocol doesn’t build in the objective data necessary to determine the true impact of a change in amount of thickener on swallowing physiology and therefore, on airway protection during the course of a true feeding. The objective data from a VFSS about the can be often surprising and indeed is often necessary for our very fragile extremely preterm infants with complex histories…. versus weaning based on subjective/clinical impressions only. The risk-benefit ratio of clinical weaning for each patient must be carefully determined, especially with former 22 weekers.

The team at Boston Children’s has provided us with a wealth of research to help inform our practice. This paper referenced below details the intervention—a protocol for weaning thickened fluids via clinical data. Its implications are far reaching, and its recommendations require critical thinking.

Wolter NE, Hernandez K, Irace AL, Davidson K, Perez JA, Larson K, Rahbar R. A Systematic Process for Weaning Children with Aspiration from Thickened Fluids. JAMA Otolaryngol Head Neck Surg. 2018 Jan 1;144(1):51-56.

Like any other protocol, the key, I think, is considering when to utilize a protocol as a guide, and considering when not to; that is, when doing so may adversely affect the risk-benefit ratio. My physician mentors over the years have referred to this process as the “art and science of medicine”.  It requires us to ask how we thoughtfully apply the findings of any study to our clinical reasoning for each patient individually, to minimize risk of adverse events.

Clearly our repeat studies according to the AAP must be completed with thoughtful justification and careful attention to risk-benefit ratio, especially with infants. It is best practice as stated in the article that “children should be transitioned to non-thickened diets as soon as it is safe to do so.”

However, reducing fluid thickness solely “based on a patient’s’ clinical response” is worrisome to me.

In pediatrics, like in adult care, patient A is not the same as patient B, even though they both have been placed on thickened liquids for clinically sound reasons. Those infants/children with more complex co-morbidities, those who silently aspirated, and those with more precarious swallowing pathophysiology would potentially have greater risk for airway invasion with changes based on clinical data alone. And there may not be clinical suspicion that the wean increases risk, as the weaning protocol proceeds. Universal application of the weaning protocol without a very clear consideration regarding these fragile high-risk feeders may inadvertently increase risk for airway invasion.

Duncan et al in their 2018 study (Duncan, D. R., Mitchell, P. D., Larson, K., & Rosen, R. L. (2018). Presenting signs and symptoms do not predict aspiration risk in children. The Journal of Pediatrics, 201, 141-146)  reported that “Presenting symptoms are varied in patients with aspiration and cannot be relied upon to determine which patients have aspiration on VFSS. The CFE (clinical feeding evaluation) does not have the sensitivity to consistently diagnose aspiration”. Their findings would likely apply to post-swallow study decisions made without benefit of objective data, and that is worrisome.

Most recently, a team at Boston Children updated its 2019 paper on thickening considerations (see citation below), and among their recommendations was this statement:

“Implementation of a systematic weaning protocol may also result in a reduction in instrumental assessments for the patient which may reduce their exposure to ionizing radiation if re-evaluating via the videofluoroscopic swallow study. However, providers must remain cautious if using this approach in infants and young children with silent aspiration, given the difficulty in monitoring symptom change while weaning in these patients…The balance between viscosity and flow rate in aerodigestive patients with oropharyngeal dysphagia needs to be based on instrumental assessment of swallow safety such as videofluoroscopic swallow study.”

Pados (2019, see citation below) further highlights the importance of assessing a feeding regimen under instrumental assessment: “When thickening of liquids is indicated, providers and families need data obtained from an instrumental assessment to guide evidence based decision-making about the safest thickened liquid consistency and type of nipple to offer to maintain a flow rate that is safe for the infant” (Pados BF, Park J, Dodrill P. Know the flow: Milk flow rates from bottle nipples used in the hospital and after discharge. Adv Neonatal Care. 2019;19(1):32–41).

Perhaps most worrisome is the possible implication from Wolters’ conclusions is the im0plication  that the value of a VFSS is to identify bolus misdirection and aspiration, rather than to objectify swallowing physiology and pathophysiology as a basis for optimal interventions and their modification. The risk-benefit ratio of a repeat VFSS must indeed be carefully considered, but we must also consider the critical impact of that objective data, about physiology, on any changes in interventions we might consider.

The more I learn, the less black and white answers I have, and I think that is good. For each patient, we will need to continue to develop an algorithm for that patient, that best minimizes risk, in the setting of that child’s unique co-morbidities, history, and the nature of the swallowing pathophysiology objectified. Pausing to consider all the pieces and reflect, will always be the key. I hope this is helpful.

Question: Is there a pediatric algorithm or current guidelines/best practices for feeding pediatric patients on high volumes of HFNC? We’re frequently being asked to conduct Bedside swallowing assessments on pediatric patients who are respiratory compromised on 10-12L of HFNC. I’m very uncomfortable with this for several reasons. Our Intensivists are open to having conversations but are asking for the EBP. Any input would be greatly appreciated! Thanks in advance!

Catherine’s Answer: Our current research-based evidence on PO feeding while requiring CPAP or HFNC is only emerging and is limited. It is not sufficient at this time to allow us to create an generic algorithm in which we can have confidence to guide the team. It underscores the high importance of our clinical wisdom —-clinical reasoning and critical thinking —- for this fragile population, whether a neonate or a pediatric patient. The plan for each patient must be considered in the context of unique history, co-morbidities, premorbid status, acuity of illness, presenting clinical course and progress, trajectory of the respiratory course (weaning support vs. need for escalation), clinical impressions and differential, and current risks to health due to potential airway invasion, as each of my colleagues has so well reinforced.

In the neonatal period, with the guiding input of the SLP, the goals would be to minimize airway invasion, avoid onset of maladaptive feeding behaviors, minimize further respiratory system morbidity and avert the adverse short and long-term effects of stress (both physiologic and behavioral), and to support the parent-infant feeding relationship. Carolyn’s 2023 publication (see below) is an excellent resource for this question regarding our NICU population. The data documenting the high risk for silent aspiration among NICU infants is quite worrisome. Our only objective research data on safety of PO feeding for those infants requiring Non-Invasive Ventilation (NIV) –is from Ferrara (2017) looking at PO feeding on CPAP; the neonatologists conducting the study halted it due to safety concerns. One of the key takeaways for me from Ferrara’s work was the need for objective data regarding the impact of NIV on the swallowing physiology of neonates being asked to PO feed on NIV. Not just whether aspiration is witnessed but the impact on swallowing physiology even in the absence of witnessed aspiration. “Tolerance” for PO on NIV in neonates has been based in most studies only on subjective data, and as such the conclusions appear tenuous. Multiple studies have shown the limitations of clinical judgement regarding airway protection during PO feeding on much less complex neonates and pediatric patients – so our NICU infants with complex respiratory co-morbidities requiring NIV very likely present added risk for silent airway invasion.

For our pediatric patients in PICU, their premorbid history and co-morbidities, and reason for admission are part of the unique problem-solving required. Otherwise- normally-developing children who are admitted with respiratory illness, or a viral process may be expected to follow a different trajectory toward recovery and may be able to take a different path toward return to PO feeding than those with premorbid feeding/swallowing problems or a complex history. There is not an algorithm of which I am aware that can confidently discern those differences and their impact, at this time. Hema’s Desai’s 2022 publication with Jennifer Raminick (see below) is an excellent resource for considerations regarding PO feeding in the pediatric population requiring high flow oxygen therapy. Rice and Lefton-Greif (2022) also reinforce a focus on patient factors in the problem-solving process about HFNC in pediatric patients, especially the setting of the trajectory of the child’s course (weaning support vs. need for escalation), and the interaction with clinical impressions and the potential risk that airway invasion may impact recovery; there is also a lit review current at that time. Our pediatric patients are also worrisome due to the added complications of a high incidence of post- extubation dysphagia, estimated to be as high as 69% in a study by DaSilva et al (2023) see below.

Cross-fertilization of knowledge through patient-specific collaboration with the team (whether in NICU or PICU) is essential. I agree this can best be accomplished by Laura’s and Hema’s suggestion to advocate for SLP consult as the starting point for patients on respiratory support so that we can help guide the PO plan case by case, via ongoing collaboration. Of note, SLP consults in PICU according to Santiago et al (2023)- who noted a decrease in SLP involvement in the PICU (at three well-respected pediatric hospitals) among patients ages 7-12 y/o with a h/o mechanical ventilation, which may reflect a trend, pending further data. While this is not the situation in all PICUs, I hear from colleagues in some that the value-added by an SLP consult is not consistently recognized and a consult is sometimes perceived as likely to “hold the patient back” or delay discharge. This can unfortunately sometimes then provoke readmissions, prolong LOS and/or adversely affect outcomes.

From my networking nationally, a dilemma is not uncommon in many pediatric hospitals across the US. The unfortunate influence of applying adult-based data to pediatric practice, a scarcity of research on neonatal and pediatric patients, an often less-than-optimal acute care SLP consult practice —that would optimally support interdisciplinary problem-solving and care —and the increasing complexity of the patients we see across the continuum of pediatric acute care, all combine to create the perfect storm. We are all in this together.

Barnes, C., Herbert, T. L., & Bonilha, H. S. (2023). Parameters for Orally Feeding Neonates Who Require Noninvasive Ventilation: A Systematic Review. American Journal of Speech-Language Pathology, 1-20.

da Silva, P. S., Reis, M. E., Fonseca, T. S., Kubo, E. Y., & Fonseca, M. C. (2023). Postextubation dysphagia in critically ill children: A prospective cohort study. Pediatric Pulmonology, 58(1), 315-324.

Rice, J. L., & Lefton-Greif, M. A. (2022). Treatment of pediatric patients with high-flow nasal cannula and considerations for oral feeding: a review of the literature. Perspectives of the ASHA special interest groups, 7(2), 543-552.

Raminick, J., & Desai, H. (2020). High flow oxygen therapy and the pressure to feed infants with acute respiratory illness. Perspectives of the ASHA Special Interest Groups, 5(4), 1006-1010.

Santiago, R., Gorenberg, B., Hurtubise, C., Senekki-Florent, P., & Kudchadkar, S. (2023). Speech pathologist involvement in the pediatric ICU. Critical Care Medicine, 51(1), 353

QUESTION:

Recently, I completed a MBSs on a 30-month-old child secondary to complaints of vomiting, gagging/choking at random. At age 24 months, child had tonsillectomy/adenoidectomy completed secondary to vomiting/gagging with the hopes this would correct child’s difficulties. MOC reports that this did help some however reports difficulties have not completely resolved. Per MOC, child had pacifier until age of 20 months. At time of MBSs child did consume pureed and thin liquids, they refuse all other bolus consistencies. Child noted to have a high palate arch and slightly narrowing in front of mouth. Delayed swallow to the level of the pyriform sinus was observed, suspect secondary to poor retraction and elevation of tongue to soft palate due to high arch. No penetration or aspiration noted. Appropriate ROM with tongue was observed during attempts at oral facial/motor examination. Per MOC, child is a picky eater, consumes 30oz of milk daily, will pocket food and spit it out and gag on water intermittently.

Based off of how this child presents, I would focus on lingual strengthening, age-appropriate mastication patterns and acceptance of age-appropriate foods. For a child of this age, what would your recommendations be for treatment/tasks to obtain these goals/exercises etc.? I am running into a roadblock per say. From my research and reading, I have found great ideas for older children or adults who follow verbal directives, however due to this child’s age, I am stuck!

ANSWER:

Is the child otherwise normally developing? Is postural /sensory-motor control age-appropriate?  I am asking because sometimes this type of clinical presentation is part of a bigger sensory processing issue or part of a constellation of craniofacial alterations or alterations across developmental domains. That creates a different “bigger picture” from which to problem-solve.

Craniofacial malformations often co-occur with changes in the muscular network that supports those structures. The high arched (and sometimes “tented”) palate can co-occur as part of a genetic syndrome and can co-occur with mandibular hypoplasia. Mandibular hypoplasia alters lingual and supra/infrahyoid muscular ROM and their functional coordination.

Interestingly, I have seen across the age span that, with this clinical presentation you described, it is not uncommon to have co-occurring tethering of oral tissues. I suspect that, if there are TOTs, this may be because the formation of these structures and muscular attachments occurs around the same time in utero. Then their motor sequences are initially mapped in utero through swallowing of amniotic fluid. So, the underpinnings for a well-integrated oral-motor system are underway quite early. Maladaptive networks also start in utero and the foundations for function can then start off in infancy already altered and impact future function that “feeds forward”, as our PT colleagues call it, in motor learning. So, implications unfold overtime.

If there are tethered oral tissues, or related alterations, they can at times be more subtle. These alterations can create challenges for the emergence of motor plans along the swallow pathway, and for bolus control and manipulation. That may also provoke the air swallowing that can lead to the vomiting/emesis you report. We must of course recognize that tethered oral tissues are not always the explanation/etiology, but should be a part of your thoughtful differential, as it could explain the functional limitations you describe. As could altered oral-facial tone, an altered overriding postural network, and/or sensory integration problems, and other possibilities, depending on the unique “bigger picture” for this child. Thinking through that bigger picture will best guide targeted interventions.

A wonderful resource on the neurodevelopmental underpinnings for feeding development is included in Robyn Walsh and Lori Overland’s book on “Functional Assessment and remediation of Tethered Oral Tissues”. Even if TOTs are not part of this child’s etiology(ies), their tutorial included in their book is not just about TOTs but is a foundational must read on functional oral motor development. By two of our wonderful SLP colleagues.

The swallow study would likely reveal any alterations in base of tongue retraction and pressure generation that may be created if tethering were impacting this child’s swallow pathway. For some children, the oral phase appears most altered, but that of course can cause problems down the line such as gagging and “sudden” loss of control which mother describes, which may reflect challenges with coordination during the dynamic swallow (when the need for exquisite motor mapping is required).

The attached article by my colleague Laura Brooks that adds to our understanding of the potential implications of some of the potential alterations. Even though with your patient there was no witnessed airway invasion, there was an alteration in physiology that likely is connected somehow to the functional differences you are seeing. This may take some peeling apart layers of data through a second and third look. Or more. And it may take a while to sort out and trial the interventions that best meet your differential. And that’s ok. It’s complex but you have a good start.

Click here for Laura Brooks article

In the neonatal and pediatric population, evidence is still emerging to guide our processes during the instrumental assessment, interpretation and analysis of pathophysiology and subsequent recommendations. Our time in radiology is such a small window, often with limited, and at times tenuous, data. We then need to consider that data in the setting of that infant’s/child’s unique co-morbidities and history, which then give meaning to the data we have collected.

There is no cookbook for pediatric swallow studies; cookbooks were made for cooking, not for instrumental assessments. Knowing potential interventions, but also what interventions would be contraindicated based on pathophysiology/history/co-morbidities is the starting point. What we then recommend may indeed tip that balance between risk-benefit, and in either direction. Optimizing the risk-benefit ratio for the infant/child requires us to utilize critical reflective thinking, with a focus on the nature of the pathophysiology, the biomechanical alteration/impairment, and its implications for that unique infant/child. In drilling down to that infant’s/child’s “story”, we then realize that a plan for baby A with the same objective data from radiology may not be appropriate for baby B.

The nature of the pathophysiology in the neonatal/pediatric population has nuances that reflect the dynamic interaction of the developmental trajectory of motor learning with evolution of the swallow. Superimposed on this, then, are the co-morbidities that increase risk, especially prematurity, CLD, CHD and other diagnoses that adversely affect cardio-respiratory integrity.

The evidence-base in the literature to guide us is emerging and is still in its infancy. Laryngeal Penetration (LP) has been associated with negative clinical outcomes in subsets of the pediatric population, including increased risk for PNA and aspiration (Gurberg et al, 2015). Duncan et al (2020) out of Boston Children s Hospital found in their study that laryngeal penetration is not transient in children < 2 years of age and may be indicative of aspiration risk. In their study, on repeat VFSS: 26% with prior LP had frank aspiration. The authors remarked that “Any finding of LP in a symptomatic child should be considered clinically significant and a change in management should be considered”. That may be a change in position, change in nipple, change in cup, adding a control valve, limiting bolus size, pacing, slow rate of intake, smaller sips, not necessarily thickening.

In such a scenario, thickening is not a solution but may be an interim step along the way to allow time for motor learning by the infant/child and for us to address the underlying pathophysiology. Thickening is not without its own attendant sequalae and is always our last resort in pediatrics. Brooks (2021) looked at potential options for thickening that may be less problematic for and better tolerated by our pediatric population, which can include certain purees, such as fruit or vegetable purees and yogurts.

Duncan et al in 2019 stated that thickened liquids are indicated “When symptoms pose greater risk than negative effects of thickeners”. In their study, intervening when penetrations were observed yielded symptom improvement, and reduced hospitalizations, especially pulmonary–related. Greatest improvement was observed with thickening (91%). Benefits of thickening when indicated via critical thinking can include swallowing safety, increased intake and parent satisfaction (Coon et al, 2016; Duncan et al, 2019, Krummrich et al 2017)

In addition, (Friedman & Frazier, 2000) from Colorado Children’s found a strong correlation between deep laryngeal penetration and subsequent aspiration in pediatric patients. Most often I find these are infants and children with complex co-morbidities, especially cardio- respiratory.

This discussion is a good one for our self-reflection. It reminds us that the dynamic swallow pathway exists only in the context of the infant or child and what their unique “story” is. Our job is to peel apart the layers of the history, co-morbidities, clinical and instrumental findings, the feeding “environment”, family input, and then thoughtfully reflect on the best plan least likely to cause adverse events. The critical thinking required is built upon organizing our thinking around not only what we know, but what we do not know (or fully understand), which remains quite broad in pediatrics. Those questions become flashlights that we shine into the darkness, allowing us to move forward into the uncertain and unknown thoughtfully. As the philosopher Bertrand Russell once remarked, “In all affairs, it’s a healthy thing now and then to hang a question mark on the things you have long taken for granted”. And so it is, I think, with the work that we do. The “answers” have a way of becoming insufficient or obsolete over time. The questions, the intellectual curiosity, must endure for us to make good clinical decisions for our little patients.

Brooks, L., Liao, J., Ford, J., Harmon, S., & Breedveld, V. (2021). Thickened Liquids Using Pureed Foods for Children with Dysphagia: IDDSI and Rheology Measurements. Dysphagia, 1-13.

Coon, E. R., Srivastava, R., Stoddard, G. J., Reilly, S., Maloney, C. G., & Bratton, S. L. (2016). Infant videofluoroscopic swallow study testing, swallowing interventions, and future acute respiratory illness. Hospital pediatrics, 6(12), 707-713.

Duncan, D. R., Larson, K., Davidson, K., May, K., Rahbar, R., & Rosen, R. L. (2020).Feeding interventions are associated with improved outcomes in children with laryngeal penetration. Journal of pediatric gastroenterology and nutrition, 68(2), 218.

Duncan, D. R., Larson, K., & Rosen, R. L. (2019). Clinical aspects of thickeners for pediatric gastroesophageal reflux and oropharyngeal dysphagia. Current gastroenterology reports, 21(7), 1-9.

Friedman, B., & Frazier, J. B. (2000). Deep laryngeal penetration as a predictor of aspiration. Dysphagia, 15(3), 153-158.

Gurberg, J., Birnbaum, R., & Daniel, S. J. (2015). Laryngeal penetration on videofluoroscopic swallowing study is associated with increased pneumonia in children. International journal of pediatric otorhinolaryngology, 79(11), 1827-1830.

Krummrich, P., Kline, B., Krival, K., & Rubin, M. (2017). Parent perception of the impact of using thickened fluids in children with dysphagia. Pediatric Pulmonology, 52(11), 1486-1494.